Outcome Indicators on Interprofessional Collaboration Interventions for Elderly

Background: Geriatric care increasingly needs more multidisciplinary health care services to deliver the necessary complex and continuous care. The aim of this study is to summarize indicators of effective interprofessional outcomes for this population. Method: A systematic review is performed in the Cochrane Library, Pubmed (Medline), Embase, Cinahl and Psychinfo with a search until June 2014. Results: Overall, 689 references were identified of which 29 studies met the inclusion criteria. All outcome indicators were summarized in three categories: collaboration, patient level outcome and costs. Seventeen out of 24 outcome indicators within the category of ‘collaboration’ reached significant difference in advantage of the intervention group. On ‘patient outcome level’ only 15 out of 32 outcome parameters met statistical significance. In the category of ‘costs’ only one study reached statistical significance. Discussion and conclusion: The overall effects of interprofessional interventions for elderly are positive, but based on heterogeneous outcomes. Outcome indicators of interprofessional collaboration for elderly with a significant effect can be summarized in three main categories: ‘collaboration’, patient level’ and ‘costs’. For ‘collaboration’ the outcome indicators are key elements of collaboration, involved disciplines, professional and patient satisfaction and quality of care. On ‘patient level’ the outcome indicators are pain, fall incidence, quality of life, independence for daily life activities, depression and agitated behaviour, transitions, length of stay in hospital, mortality and period of rehabilitation. ‘Costs’ of interprofessional interventions on short- and long-term for elderly need further investigation. When organizing interprofessional collaboration or interprofessional education these outcome indicators can be considered as important topics to be addressed. Overall more research is needed to gain insight in the process of interprofessional collaboration and so to learn to work interprofessionally.


Introduction
The ageing of the population is expected to be a major driver of increasing demand for long-term care multidisciplinary services [1,2]. An average of 81% (for Belgium 84%) Europeans prefers to be cared for in their homes either by relatives or by professionals, whereas only 8% (for Belgium 11%) prefers to be cared for in a longterm care institution [3]. Delivery of health care for the ageing population will therefore require more and high levels of inter-disciplinary teamwork or 'interprofessional collaboration' [4][5][6]. The extent to which different health care professionals work inter-disciplinary well together affects the quality of the health care that they provide [7][8][9]. Distinctions between the terms multi-disciplinary and inter-disciplinary (or interprofessional) are important. Interprofessional collaboration (IPC) is a model of different disciplines (inter-disciplinary) working together [10][11][12] and assumes a process by which professionals develop an integrated and cohesive answer to the needs of the care receivers and their social system [13,14]. In multiprofessional collaboration on the contrary, appropriate experts from different disciplines handle problems of care receivers independently. The care receivers' problems are subdivided and treated separately, with each provider responsible for his/her own area so it is more an additive collaboration rather than an integrative collaboration as in IPC [15]. Despite the large amount of publications on IPC, still a higher quality of research, evidence and more rigorous evaluation is needed to understand the effectiveness of IPC and to support decision makers [9,16]. Studies should provide insights into how interventions affect collaboration and how improved collaboration contributes to changes in outcomes on patient level and especially quality of care [9]. Over the years different studies tried to indicate positive effects of IPC and interprofessional education (IPE) in practice for outcomes on patients [9,17]. However indicators to measure the effect of IPC in order to learn to collaborate interprofessionally, are still not well investigated nor standardized [18,19]. A summary of outcome indicators used to measure the effect of IPC interventions for elderly, can help to organize IPC and to develop IPE. An overview of effective indicators of IPC can help to gain insight in how interventions affect collaboration and how improved collaboration contributes to changes in outcomes for elderly. This review aims to summarize outcome indicators used to measure the effect of IPC interventions for elderly.

Search strategies
A systematic search was performed for articles published between 2007 and June 2014. This search for relevant publications repeated the strategy used by Zwarenstein et al 2009 [9] as a starting point not with the aim to update the review. Databases used were The Cochrane Library, Pubmed (Medline), Embase, Cinahl and Psychinfo. Only literature published between 2007-and June 2014 was included. The search strategy employed the following terms: interprofessional relations, patient care teams, interprofessional, multidisciplinary and transdisciplinary collaboration strings as used can be found in annex.

Selection criteria publications
For the search five independent readers (GT, NC, VV and MLH) selected the references on the basis of title and abstract using the following inclusion criteria: a practicebased IPC intervention was the topic of the study and outcomes were reported on the effect of the IPC intervention with a relevance for elderly. We also reviewed the selected studies on description of the intervention and the control group. An IPC was considered when there was a model of working together between different disciplines and with the awareness of the process by which health care professionals developed an integrated and cohesive answer to the needs of the care receivers and their social system, a common vision and purposeful approach and shared responsibility [13,14,20].

Study quality appraisal
The selected papers were screened on full text by two reviewers (GT and PVR) and assessed with the use of the Dutch Cochrane assessment instruments for evaluation of systematic reviews, for evaluation of RCT's, cohort studies and qualitative research [21].

Data extraction
For all included studies the characteristics were reported including year of publication, study design, population, aim, intervention and control, and finally outcome (see Table 2).

Results
Overall, 689 references were identified by the search, of which 57 were eligible on the basis of their title and abstract. Finally, 29 publications met the inclusion criteria after critical appraisal ( Table 1) on full text and were included for the review (Figure 1). In general the interventions were described well enough to decide whether an intervention could be identified as 'interprofessional' or not. However the description of the control group was not always well described to know the exact difference between 'interprofessional collaboration' as intervention and the 'other' collaboration.

Collaboration
Seventeen out of 24 outcome indicators within the category of ' collaboration' reached significant difference in advantage of the intervention group ( Table 3). Within the category of ' collaboration' the sub-indicator outcomes are key elements, involved disciplines, satisfaction by professionals and by patients and finally quality of health care.

Key elements
Seventeen of the included studies reached a statistically significant effect of interprofessional collaboration as an intervention by using (organizing) coordinated collaboration or special programs ( Table 3). Nazir et al (2013) investigated the impact of multidisciplinary rehabilitation on health outcomes of nursing homes residents. Team communication and coordination were confirmed as consistent features for successful collaboration [25]. Mudge (2014) reported in the implementation of an interprofessional care model, including greater allied health staffing, consistent interdisciplinary teams, structured daily interdisciplinary meetings and explicit discharge planning. This interprofessional care model seemed effective for patients admitted from residential aged care [24]. 'Guided Care' scored significantly higher on quality of care [22,23]. Participants receiving guided care reported also significant higher scores on knowledge about and satisfaction for goal setting, coordination of care, problem solving, patient activation and aggregated quality in comparison with receivers of usual care, up to 18 months follow up [23]. In the quality improvement initiative in the study of Ryvicker et al (2011), the findings highlight the challenges of relying on peer-to-peer spread, and of distinguishing the core elements of an effective improvement strategy. Leaders should develop explicit communication plans and commit resources to implement the quality improvement initiatives over time [26]. Rantz et al (2013) described the influence of interprofessional teams to sustain quality improvement in nursing homes that 'need improvement'. Active participation of the leaders increases the chance for success of implementing quality improvement projects [27].

Involved disciplines
Chapman et al (2007) reported social workers played an important role in coordinating the work of the multidisciplinary team and especially in involving family members in care planning and interventions. Although the teams were significantly effective in reducing agitated behaviour Summary key element reported in the studies: -Goal setting [22,23] -Team communication [24][25][26] -Coordination of care decision support [22][23][24][25][26] -Patient activation [23,25] -Care (and discharge) planning [24][25][26] -Kind of contribution of involved disciplines [25][26][27] -Leadership [25][26][27]  The focus of this analysis was on the use of team and group processes by the nursing home staff in quality improvement efforts.
Facilities in resident outcome "need of improvement" received multilevel intervention designed to help them (quality improvement methods and team and group process for direct-care decision-making. . .) The focus of this analysis was on the use of team and group processes by the nursing home staff in quality improvement efforts.
Description of behavior of staff in intervention facilities during a RCT for improving quality of care and subsequently improving resident outcomes in nursing homes.    and pain of the residents, no effect was found on the level of collaboration and coordination itself [28]. In two out of three studies [29][30][31] interventions targeting pharmaceutical care including general practitioners and pharmacists showed significant effects. In the study of Denneboom et al (2007) pharmacists suggested the changes in medication to the general practitioners after medication review. Case conferences on prescription-related problems resulted in more medication changes than written feedback [30]. Clinical medication reviews in collaboration with general practitioners can have a significant positive effect on the 'Medication Appropriateness Index'. However pharma-cist withdrawal from the study suggest that community pharmacy may not be an appropriate environment from which to expand clinical medication reviews in primary care [29]. Interviewing patients, development and implementation of pharmaceutical care plans together with patients' general practitioners and monthly medication reviews with patients performed by pharmacists did not reach any significant changes in appropriateness of prescribing medication [31]. In contrast, participation of primary physicians and/or a pharmacist in the interprofessional intervention, as well as team communication and coordination, were consistent features of successful interventions [25]. It seemed beneficial for the quality of care for chronic disease management to expand traditional family practice with pharmacists or nurse practitioners who focus on the management of this specific group of older, complex patients [32].

Professional satisfaction
In the study of Boult (2008) guided care had a positive effect on changes in physicians satisfaction for communication with patients, family caregivers, educating family caregivers, motivating patients to participate in maximizing their health, referrals to community resources and change in knowing all the medication patients are taking [22]. The burden of the care in a multidisciplinary rehabilitation for elderly with hip fracture, as rated by the Caregiver Strain Index was reported to be statistically and clinically significantly less for care providers of participants of home-based group [33]. Primary care providers' satisfaction in the study of Phelan et al (2007) in investigating effective primary care to elderly was positive for intervention but not statistically significant [34].

Patient satisfaction
When receiving a comprehensive continuum of care intervention, frail older people perceived quality of care significantly higher [35]. More specially the items about care planning in the intervention group were rated higher than the control group at three-and 12 months followups. Guided care also improves self-reported quality of chronic health care for multi-morbid older persons [23]. The reported patient satisfaction for the multidisciplinary team care for elderly was significant higher in community hospitals than in general hospital care [36].

Quality of health care
In six studies effect on quality of health care was investigated [22,23,32,34,37,38] [22,23]. In the study of Counsell et al (2007) effect on quality of care was measured with 'Assessing Care of Vulnerable Elders' [37]. In the study of Hogg et al (2009) effect on quality of care for chronic disease management was found using a form of collaborative multidisciplinary care teams as intervention [32]. In all four of the above mentioned studies a positive statistical significance was reached in favour for the intervention [32]. In the study of Phelan (2007) and Wu (2010) no statistical difference was found for quality of care indicators [34,38].

Patient outcome level
On 'patient outcome level' only 15 out of 32 outcome parameters were to be understood as effective, by reported statistical significance ( Table 3). Within the category of 'Patient level outcome' the sub-indicator outcomes are pain, fall incidence, quality of life, independence, depression and behavior, transitions, length of stay (LOS) in hospital, mortality and period of rehabilitation.

Pain
One study found a positive effect of an interprofessional intervention for decreasing pain, using the Faces Legs Activity Cry Consolability (FLACC) and Pain in Advanced Dementia (PAINAD) scales [28].

Fall incidence
Two studies targeted effects on fall incidence and fallrelated injuries and were successful in significantly decreasing fall incidence and slips and trips [39,40]. Three studies, including two systematic reviews, did not report significant decrease of fall incidence as a result of interprofessional interventions [41][42][43].

Quality of life
Effect on quality of life was found in the study of Counsell et al (2007) implementing a geriatric care management model on improvement of the quality of care [37]. Bryant et al (2011) investigated the influence of involvement of community pharmacists on improvement in medicine related therapeutic outcomes for patients. Quality of life and medication appropriateness index increased because of interdisciplinary pharmaceutical care [29]. There were no statistically significant differences favouring the intervention group in a systematic review on multidisciplinary rehabilitation for elderly with hip fractures [33]. Also in the RESPECT (Randomized Evaluation of Shared Prescribing for Elderly people in the Community over Time) model of wherein pharmaceutical care was shared between community pharmacists and general practitioners, no significantly changes were reported on the quality of life for elderly [31]. Also the Stroke unit study (2009) did not report on statistically significant changes for quality of life [44].

Independence
In four out of eight studies significant effects were found on independence for older people needing rehabilitation and receiving an interprofessional intervention [26,28,33,34,36,37,40,44].

Depression and behaviour
The results on clinical outcomes for collaborative care management on treatment response for depression seemed effective on the long-term (24 months) for young-old patients (aged 60-74) [45]. Advanced illness care teams for nursing home residents with advanced dementia were found effective in reducing agitated behaviour and pain but not depression [28].

Transitions and LOS hospital
In the study of Counsell et al (2007) emergency department visits and hospital utilization were reduced through geriatrics interdisciplinary team that provided ongoing care management [37]. A multidisciplinary team intervention did not significantly reduce the risk of transitions for individuals with dementia relocating to assisted living [46]. Even though hospitalized elderly patients are treated with consideration of their specific needs, health care outcomes visits to emergency departments did decrease, but not significantly [47]. In multidisciplinary rehabilitation participants of the intervention group had overall shorter hospital stays as reported in the systematic review of Handoll [33]. In the study of the stroke unit (2009) for length of stay in in the stroke unit group a modest reduction was found [44].

Mortality
In four studies [24,33,40,44] mortality was explicitly mentioned, of which in two significant difference was found [24,44]. Stroke patients who received multidisciplinary organized care were more likely to be alive one year after the stroke [44]. Patients admitted from residential aged care receiving the interprofessional intervention had a significant reduction in in-hospital mortality [24].

Period of rehabilitation
In the study of Handoll (2009) the hospital stay was shorter for the intervention group, but the period of rehabilitation was longer (not statistically) [33].

Costs
In the category of ' costs' only one study reached statistical significance ( Table 3). In the study of Counsell et al (2009) targeting the costs of interprofessional collaboration programs, neutral cost over two years was reported for patients at high risk of hospitalization from the healthcare delivery system perspective. For patients at low-risk of hospitalization the costs differed statistically significant in disadvantage of the intervention [37]. In three studies with all different periods of measuring costs to use health services with a multifactorial, interdisciplinary team approach, no statistical differences were reported [33,39,48].

Discussion
The aim of the study was to summarize indicators of effective interprofessional collaboration for elderly. It has to be acknowledged that due to the strict methodology, relevant studies could have been missed. During the process of summarizing the indicators the reviewers categorized the indicators in three categories. This strategy helped to gain insight into what is being investigated in order to measure possible effects of interprofessional interventions.
The overall effects of interprofessional interventions are positive, but based on heterogeneous outcomes. Exploring the outcomes gave an overview of outcome indicators with interprofessional collaboration as intervention.
Within the category of ' collaboration' the key elements target important criteria for interprofessional collaboration to be measured. Goal setting, team communication, coordination of care decision support, patient activation, care planning and discharge planning, kind of contribution of disciplines and leadership seem to be important key elements for interprofessional collaboration. Moreover, the way of communication and medication appropriateness in pharmaceutical care, seemed important outcome indicators [29,30] that effected the quality of life for patients [29].
Despite the positive effects found favouring interprofessional collaboration on health care outcomes, still too many outcome indicators remain without effect or were reported with a poorness of evidence. Moreover, we noticed that the existing collaboration within the usual care is rarely described. This makes it difficult to fully understand the difference with the usual care and what makes the interprofessional collaboration as intervention effective. From the results it seemed not possible to summarize the process how collaboration was experienced differently from the usual care. From another perspective it is generally accepted that working in an interprofessional team involves group dynamics and leadership. In the systematic review of Nazir et al (2013) this perspective was confirmed [25]. Several studies educated the professionals of the intervention group [22,47,48], but with the information from the publication we could not identify how and with which aim they were trained. It was not clear whether the education was on how to work together or just on being able to perform the intervention as standardized as possible. So no conclusions can be made on learning goals in training to learn to collaborate interprofessionally. In terms of quality of care regarding the definition by Donabedian [49] most of the studies measured effect of interprofessional collaboration on the level of technical performance, only few described the effect on level of interpersonal procedures [22,34,47].
Several outcome indicators concerning interprofessional care effectiveness for elderly on patient level outcome were found. Pain, fall incidence, quality of life, independence for daily life activities, depression and agitated behaviour, transitions, length of stay in hospital, mortality and period of rehabilitation seem the most prominent outcomes in the included literature to identify effect of interprofessional collaboration for this specific population. However, as mentioned in the study of Rantz (2013) [27], teams can fully, partial or not adopt new ways of working when implementing interprofessional collaboration strategies. This should always be taken into account when teaching and so implementing models of interprofessional collaboration in practice. If one wants to show effect of interprofessional collaboration, the intervention should also last long enough and be well described so difference with usual care is also clear.
To enhance insights in possible bottlenecks in interprofessional care delivery it can be important to include the influence of professional and personal relationships within the team and with the patients. In the studies of Nazir (2013) [25] and Boult (2008) [22], the professional relationships as key elements were very well described. This gave insight in how interprofessional collaboration is to be understood in their context. Also the patients appreciated the knowledge about the goals of the care they received. Therefore it seems important that interprofessional collaboration is to be clearly described and implemented long enough to know what effects it can have on patient level. Based on the three included studies involving costs of interprofessional collaboration, no general conclusion can be drawn on that category.

Conclusion
Overall, outcome indicators of interprofessional collaboration for elderly with a significant effect can be summarized in three main categories: ' collaboration', 'patient level' and ' costs'. For ' collaboration' the outcome indicators for IPC are key elements of collaboration, involved disciplines, professional and patient satisfaction and quality of care. On 'patient level' the outcome indicators are pain, fall incidence, quality of life, independence for daily life activities, depression and agitated behaviour, transitions, length of stay in hospital, mortality and period of rehabilitation. 'Costs' of interprofessional interventions on short-and long-term for elderly need further investigation. When organizing interprofessional collaboration or interprofessional education these outcome indicators can be considered as important topics to be addressed. Overall more research is needed to gain insight in the process of interprofessional collaboration and so to learn to work interprofessionally.